SOAP Notes
A 45-year-old patient tells you, "I've had a pounding headache behind my eyes for three days." Where does this information belong?
What is SUBJECTIVE
A patient arrives with "bradycardia" noted on their chart. Based on the prefix, should you expect their heart rate to be above or below normal range, and what intervention priority does this suggest?
Below normal range (brady- means slow); this requires monitoring as slow heart rate can indicate cardiac issues or inadequate circulation.
A patient is scheduled for an "appendectomy." Based on the suffix, what will happen to their appendix, and is this a diagnostic or treatment procedure?
It will be surgically removed (-ectomy means surgical removal); this is a treatment procedure.
A patient complains of "gastralgia." Breaking down the root word, which organ system is involved, and what is the patient experiencing?
Digestive system/stomach (gastr/o = stomach); the patient is experiencing stomach pain (-algia = pain).
An order reads: "Acetaminophen 500mg PO Q6H PRN pain." When and how should the patient receive this medication?
By mouth (PO), every 6 hours (Q6H), as needed (PRN) for pain. Patient takes it orally when they have pain, up to every 6 hours.
During examination, you measure the patient's blood pressure at 142/90 mmHg. You document this finding in which section?
What is Objective
A prescription reads "subdermal injection." Using the prefix, explain the route: where will the medication be administered relative to the skin layers?
Below or beneath the skin layers (sub- means under/below).
The doctor orders a "colonoscopy." Using the suffix, explain what type of procedure this is and whether it involves cutting tissue.
Visual examination using a scope (-scopy means visual examination); no cutting—it's a diagnostic procedure using a camera.
A diagnosis reads "nephropathy." Using the root word, identify which organ is diseased and what body system you should assess.
Kidney (nephr/o = kidney); assess the urinary/renal system.
Vital signs show: "BP 120/80, HR 72, RR 16, T 98.6°F." Which abbreviation represents the patient's breathing rate, and is this value within normal limits?
RR = respiratory rate (breathing rate); 16 breaths per minute is within normal limits (12-20 is normal for adults).
You document: "Patient reports 8/10 pain that worsens with movement and describes it as 'sharp and stabbing.'" The pain rating and description belong in which section, and why might the patient's exact words matter?
What is Subjective; the patient's exact words provide important details about the quality and severity of pain that help with assessment and diagnosis.
A lab report shows "hyperglycemia." The prefix tells you the glucose level is abnormal in which direction? What patient education might you anticipate providing?
Above normal/elevated (hyper- means excessive/above); education about blood sugar management, diet, and possible diabetes.
A patient's diagnosis includes "arthritis." The suffix indicates what is happening in their joints? How does this differ from "arthralgia"?
Inflammation (-itis means inflammation); arthralgia means joint pain (-algia = pain) without inflammation.
A patient has "dermatitis" documented. Using the root word, which body organ/system is inflamed, and what visible signs might you observe?
Skin (dermat/o = skin); visible signs might include redness, rash, swelling, or irritation.
A note states: "Patient c/o SOB x 2 days." Translate this into plain language—what symptom is the patient experiencing and for how long?
Patient complains of (c/o) shortness of breath (SOB) for (x) 2 days.
After reviewing the patient's symptoms and vital signs, you write: "Likely viral upper respiratory infection based on presentation." Which section contains this clinical judgment?
What is Assessment
A patient has "bilateral pneumonia" documented. Using the prefix, how many lungs are affected, and how might this change the severity compared to unilateral pneumonia?
Both lungs (bi- means two); bilateral involvement is typically more severe and may require more aggressive treatment than single-lung infection.
A chart shows both "rhinorrhea" and "otorrhea." The suffix tells you what is occurring, but from which two different body locations?
Discharge or flow (-rrhea means discharge/flow); rhinorrhea = nasal discharge (runny nose), otorrhea = ear discharge.
Lab work shows "leukocytosis." Using the root words, explain what type of blood cell is elevated and what this might indicate about the patient's condition.
White blood cells (leuk/o = white, cyt/o = cell); elevated white blood cells often indicate infection or immune response.
A chart reads: "Pt has hx of hypertension and diabetes." What does "hx" mean, and why is this information important for current treatment?
"hx" = history; this tells you the patient's past medical conditions, which helps avoid drug interactions, understand current symptoms, and guide treatment decisions.
"Prescribe ibuprofen 400mg PO TID, advise rest and hydration, follow up in 5 days if symptoms persist." This represents which section, and what distinguishes it from an Assessment?
What is Plan; the Plan outlines specific interventions and next steps, while Assessment is the diagnosis/conclusion. Plan is action-oriented.
A chart notes "tachypnea" and "tachycardia" in a patient. Both prefixes indicate what type of change? What underlying condition might cause both symptoms simultaneously?
Both indicate fast/rapid rates (tachy- means fast); possible causes include infection, fever, anxiety, shock, or cardiovascular problems.
A patient needs a "tracheostomy" due to airway obstruction. Compare this to a "tracheotomy" using suffix analysis—which is temporary and which is permanent, and why does the suffix difference matter?
Tracheostomy (-ostomy) creates a permanent opening; tracheotomy (-otomy) is a temporary incision. -ostomy = permanent opening, -otomy = cutting/incision.
A patient has both "cardiomegaly" and "hepatomegaly" noted on imaging. Using root words, identify which two organs are enlarged. What might cause both organs to be affected simultaneously?
Heart (cardi/o) and liver (hepat/o) are both enlarged (-megaly = enlargement); possible causes include heart failure causing liver congestion, or systemic conditions affecting multiple organs
An X-ray report states: "fx of left radius confirmed." What does "fx" mean, and what type of treatment would you anticipate for this patient?
"fx" = fracture (broken bone); treatment might include casting, splinting, pain management, or possibly surgery depending on severity.